Research ArticleThe Role Descriptions of Triage Nurse in EmergencyDepartment: A Delphi Study

Mohsen Ebrahimi,1 Amir Mirhaghi,2 Reza Mazlom,2 Abbas Heydari,2

Asra Nassehi,3 and Mojtaba Jafari4

1Department of Emergency Medicine, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad 9137913316, Iran2Evidence-Based Caring Research Center, Department of Medical-Surgical Nursing, School of Nursing and Midwifery,Mashhad University of Medical Sciences, Mashhad 9137913199, Iran3Research Center for Health Services Management, Institute for Futures Studies in Health, Kerman University of Medical Sciences,Kerman 7616913555, Iran4Department of Medical-Surgical Nursing, Faculty of Nursing and Midwifery, Bam University of Medical Sciences,Khalije Fars Boulevard, Bam, Kerman 7661771967, Iran

Correspondence should be addressed to Amir Mirhaghi; mirhaghia@mums.ac.ir

Received 2 December 2015; Accepted 19 April 2016

Academic Editor: Toomas Timpka

Copyright © 2016 Mohsen Ebrahimi et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

Background. Triage nurses play a pivotal role in the emergency department. However some researchers have attempted to expandtriage nurse’s role; remarkable discrepancies exist among scholarly communities.The aimwas to develop a role description of triagenurse relying on the experts.Methods. Amodified Delphi study consisting of 3 rounds was performed fromMarch to October 2014.In the first round, an extensive review of the literature was conducted. Expert selection was conducted through a purposeful sampleof 38 emergency medicine experts. Results. Response rates for the second and third rounds were 37% and 58%. Average age ofpanelists was (38.42±5.94) years.Thirty-nine out of 54 items reached to the final round. Prioritizing had the higher agreement rateand least agreement on triage related interventions. Conclusion. Triage nursing as a relatively new role for nurses needs significantdevelopment to be practiced. Comprehensive educational programs and developmental research are required to support diagnosticand therapeutic interventions in triage practice by nurses.

1. Introduction

Triage is defined as prioritizing or sorting the patients for thecare and treatment that is due to shortage of the necessaryresources in the emergency department (ED) [1]. Severalstudies have focused on the validity and reliability of triagescales [2, 3] and assessed agreement between nurses andphysicians [4, 5]. Factorswhich affect triage practicewere alsostudied [6]. Some studies have explored triage nurse’s dailyjob activities as well as how they decided to allocate patientsto triage categories [7, 8] but researchers rarely try to describetriage nurse job.

In response to overcrowding, some studies tried toexplain increased efficiency of triage process regarding

expanding physician and nurses roles in the triage room [9–12] in which placing a senior emergency physician with thetriage nurse reducedwaiting times for nonemergent cases [10]so the concept of team triage has been evolved. Of course, it isclear that it is not possible formost EDs to have a senior emer-gency physician in the triage room. In order to customizepatient flow more consciously and despite high satisfactionamong staff and patient, initiating X-rays by triage nursesdid not reduce transit times for patients with limb injuriesin ED [13]. In contrast, some studies have indicated triagenurse ordering seems to be an effective intervention to reduceED length of stay in patients with injuries [11]. Thereforefindings revealed that triage nurses’ role is challenging in theED.

Hindawi Publishing CorporationScientificaVolume 2016, Article ID 5269815, 6 pageshttp://dx.doi.org/10.1155/2016/5269815

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Role description is designed to guarantee the best possibleperformance by employees. In this way, the emergencyassociations have tried to develop position statement todefine triage nurse role in order to secure patient safetyin triage room. All associations have indicated that triagemust be performed at least by a registered nurse. Despiteremarkable discrepancies among statements, triage nursesare required to perform prioritizing of the patient care, takeeducational programs, and provide a safe environment as wellas interpersonal qualifications needed to fulfill this role [14–17]. However, only the Emergency Nurses Association (ENA)has comprehensively indicated several educational programs(CPR, ALS, ENPC, TNCC, GENE, CEN, and CPEN) in addi-tion to other triage educational programs [14]. Furthermoreinterpersonal qualifications including interpersonal, interdis-ciplinary, critical thinking, and communication skills as wellas accurate decisionmaking have been stated by several emer-gency associations [14–17]. However advanced practice nurs-ing roles have been recommended to improve patient flowthrough the ED [18]; advanced practice nursing roles havebeen rarely addressed by emergency associations. Even theRoyal College of Nursing has indicated triage related inter-ventions such as administrating analgesia [17], so it concludedthat role description of triage nurse suffered from lack of anintegrated approach. There is a strong possibility that it alsoaffects the reliability and validity of decisions among triagenurses in the ED.

Delphi method as an iterative process is to exploreimplicit information leading to differing judgments andsearch information which may generate a consensus onbehalf of the respondent group [19]. It has been employedby many nurse researchers in a wide variety of studies [20].So Delphi method was used to develop a role description oftriage nurse relying on the emergency medicine experts.

2. Materials and Methods

A modified Delphi study consisting of 3 rounds was per-formed from March to October 2014. Anonymity, iterationwith controlled feedback, and statistical consensus wereincluded in the Delphi method [20].

The study was approved by the Research Ethics Commit-tee at the Mashhad University of Medical Sciences. Confi-dentiality and anonymity of the experts’ participation weresecured. It was clearly defined that there is no obligation forthem to reply to the questionnaire.

In the first round, an extensive review of the literaturewas conducted [21]. Main question of the study was, what arethe attributes of the triage nurse role? Electronic databaseswere searched from inception to February 2014. Medline(Pubmed) and Scopus were searched without any additionalfilter. The keywords searched alone and in combination were“triage”, “nurse”, “role”, “Job”, “analysis”, “position”, and“statement”. Titles and abstracts were reviewed to identifythe relevant studies in the primary review. In the secondaryreview, articles were included only if the study defined role ofthe triage nurse. Studies were excluded if they have not beenapproved by emergency associations or colleges. Extendedreview was conducted to retrieve additional studies using

search engines. Data were extracted from relevant articlesbased on researchers’ agreement to identify attributes ofthe triage nurse contributing to the generation of itemspool to compose the primary questionnaire. Researcherscontinued to collect data until they reach a point of datasaturation. In the first round, selecting items for primaryquestionnaire were based on the three researchers’ consensus.Each researcher rated relevancy of items using Likert-typescale items (5: completely, 4: mostly, 3: moderately, 2: slightly,and 1: not at all). Average of rated responses was reported foreach item (Figure 1).

Expert selection was conducted through a purposefulsample of 38 emergency medicine experts and emergencynursing scholars. They were involved in emergency medicineand emergency nursing, so they were invited to take part.Experts were ED directors and physicians or nurses whohave known interest in triage practice and research. Potentialcontributors were retrieved from triage committees andassociations, authors of triage publications, and publishedarticles. All contributors were individually communicated byemail.

In the second round, an initial task list of triage nurserole was sent to the expert panelists in May 2014. Fifty-fouritems were included in the questionnaire. Items were relatedto the domains including basics, ethics, triage assessment,decision making, informing, competencies, environment,and documentation. Expert opinions on proposed tasks wereobtained by responses on a 5-point Likert scale (1: stronglydisagree, 2: disagree, 3: undecided, 4: agree, and 5: stronglyagree). Participants were asked to comment on any itemsas needed. Completed questionnaires were analyzed andagreement on each item was reported.

In the third round, a modified questionnaire was sent tothe expert panelists in July 2014. Participants were informedabout the opinion of other colleagues as well as theirs. Bothsecond- and third-round questionnaires were sent to all theindividuals regardless of their contributions in the secondround. Two reminders sent to the participants who did notreply. Reminders were sent at two-week interval.

Proportions and percentages were calculated for ordinaldata of Likert-type response scale. The data of each iterativeround was analyzed using MS Excel (2007). Only stronglyagree and agree responses to items were assumed as approveditems [22]. Each approved item which obtained a consensuslevel of 80% was identified for the next phase. The feedbackfor each round contained statistical result from the formerround, which included the consensus level reached for eachitem.

3. Results

Six expert panelists of 38were female. Average age of panelistswas (38.42± 5.94). Most participants had a medical degree inemergency medicine. All participants had an affiliation witha university hospital.

3.1. Round One. Twenty-three studies were chosen among353 articles which have been retrieved through search-ing databases and 7 were included in the final analysis.

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330 obvious irrelevantarticles excluded in

primary review

20 articles excluded insecondary review13 irrelevant to triage practice5 irrelevant to role analysis2 with abstracts unavailable

7 articles used in thestudy

4 articles included inextended review

23 articles selected forsecondary review

353 articles identified (“triage”,“nurse”, “role”, “Job”, “analysis”,

“position”, and “statement”)

Figure 1: Study selection process.

Sixty-two items were primarily extracted from the final stud-ies and redundant items were merged together, remaining 54items in the list (Table 1).

3.2. Round Two. Response rate for the second round was 31%(14/38). The number of items which remained in the end ofthe round was 43 (80%). Forty-one percent (22/54) of itemsachieved a complete consensus. 11 items were excluded sincethey did not reach a consensus level of 80%. Excluded itemsincluded legal issues (triage nurse responsibility for patientstatus and handing over level I patients to the emergencynurses and reconsidering their decisions); informing issues(informing patients about assigned triage level, their con-dition, outcomes, and potential care and treatment); ethicalissues (empathy and tactfulness characteristics); and otherissues (mandatory research participation and responsibilityfor triage room facilities and condition). Four new items wereproposed including diagnostic and therapeutic interventionsand added to the next round questionnaire (49 items). Four(7%) items were suggested to be edited lightly by participants(Table 1).

3.3. Round Three. Response rate for third round was 58%(22/38). The number of items which reached to the end ofthe round was 43 (88%). Fifty-five percent (27/49) of itemsachieved a complete consensus. Seven items were excludedsince they did not reach a consensus level of 80%. Excludeditems included ethical issues (having patience); competencyissues (continuing education); and other issues (diagnosticand therapeutic intervention and physician participations).

No item was proposed for the next round questionnaire (39items) (Table 1).

4. Discussion

Triage related interventions still need extensive developmentto be reliable enough to practice by triage nurses. Our resultsdid not reveal substantial agreement on triage nurse ordering(Table 1) which is consistent with most position statementson triage nurse role [14–17]. However some studies supporteddiagnostic interventions by triage nurse as well as advancedpractice nursing roles [11, 18, 23]; scientific evidence is limitedto ensure significant impact on patient flow in the emergencydepartment and efficiency [24]. Despite this inconsistency,expanding the role of triage nurse caused significant increasesin nurses’ satisfaction [12]. Further studies are needed todevelop more clarification of the contextual factors relatedto the interventions and investigate the impact of them onthe ED measures as the next generation of triage studies.Educational preparation and organized teamwork are essen-tially required for advanced practice role to be successfullyimplemented [25]. So prioritizing care and introducing fasttrack for patients were known as the fundamental role fortriage nurse which is unique to the emergency departmentand associated with desirable outcomes [24].

There is broad consensus that nurses are accountable forensuring safe triage practices [14–17]. Our results did notindicate a broad consensus among clinicians that physiciansroutinely perform triage in ED (Table 1). Several studiesdemonstrated that intelligent use of physicians in triagecauses substantial improvement in ED patient flow and

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Table 1: Participants’ responses to the questionnaire.

Items First round%(𝑛 = 3)

Second round%(𝑛 = 14)

Third round%(𝑛 = 22)

Prioritizing patients must be based on patients’ acuity 100 86 91Prioritizing patients must not be affected by ED overcrowding andfinancial status of patients 66 86 100

Triage decisions must be made based on evidence 100 100 100Triage decisions must be made based on reliable and valid algorithm 100 100 100Triage nurse is responsible for patients status until the first physicianvisit 66 71∗ —

Patients must be assigned to the triage levels based on relevant acuity 100 100 100Nurses are not allowed to reject patients from ED 100 93 95Nurses must be committed to the patient bill of rights 100 100 100Nurses must identify themselves to patients 100 100 100Nurses must have empathy toward patients 66 64∗ —Patients’ culture and value must be respected by triage nurses 100 93 100Triage nurses must manage ethical conflict in triage decisions 100 93 91Triage nurses must manage aggressive patients effectively 100 93 86Triage nurses must have patience 100 100 77∗

Triage nurses must handle conflict in a tactful manner 100 57∗ —Triage nurses must have interpersonal skills 100 100 100Triage nurses must perform the first assessment in the ED 100 100 100Triage nurses must estimate life-threatening risk of chief complaints 100 100 100Except in life-threatening conditions, triage nurses must observepatients at least in 2 minutes 66 86 82

Triage nurses must prioritize patients based on assessing respirations,pulse rate, blood pressure, temperature, O

2saturation, and other

diagnostic measures66 93 100

Patients should be reassessed when needed 100 100 100Triage decisions must be recorded 100 100 100Triage nurses must follow organization’s guidelines during decisionmaking 66 86 90

In case of doubt, triage nurses must consult with attending physicianor head nurse 100 93 100

In case of doubt, triage nurses must assign patient to the higher levelof acuity 100 100 100

Triage nurses must reconsider their decisions if requested frommedical directors 100 64∗ —

Level I patients must be directed to the CPR room promptly 100 93 100Level I patients must be handed over to the emergency nurses 100 71∗ —Patients must be informed in either verbal or written way regardingtheir assigned triage level 66 64∗ —

Patients must be informed that they must inform triage nurses in caseof deterioration in their health status 100 86 77∗

Triage nurses must explain waiting time to the first visit 66 93 82Triage nurses must explain necessary information relating to thepatient condition 100 71∗ —

Triage nurses must explain necessary information relating toalternative facilities for care and treatment 100 71∗ —

Triage nurses must be aware of alternative health care facilities 100 93 91Triage nurses must have a minimum degree of BS in nursing 100 93 82Triage nurses must have a minimum 2-year experience in ED 100 100 100Triage nurses must have a minimum 40-hour educational coursesannually 66 100 73∗

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Table 1: Continued.

Items First round%(𝑛 = 3)

Second round%(𝑛 = 14)

Third round%(𝑛 = 22)

Nurses must be knowledgeable about clinical semiology 100 100 100Nurses must be knowledgeable about advanced and basic adult lifesupport 100 86 82

Nurses must be knowledgeable about emergencies 100 100 100Nurses must be knowledgeable about gynecological, maternal,neonatal, children, and geriatrics emergencies 100 100 100

Nurses must be knowledgeable about outcome of disease 100 71∗ —Nurses must participate in at least one emergency research 100 50∗ —Triage roommust be somewhere between emergency department andsecurity room 100 100 100

Triage room must be easily recognizable for patients 100 100 100Triage room must have an appropriate view on entrance of ED 100 100 100Triage room must be accessible for ambulances, stretchers, andwheelchairs 100 100 100

Triage room must be at least 12 square meters 100 79∗ —Triage room must be equipped for professionals standard infectioncontrol precautions 100 93 82

Triage room must have alarm, telephone, and closed-circuit television 100 100 100Triage nurses are responsible for facilities of triage room 100 79∗ —Triage nurses are not permitted to leave the triage room, except forhanding over level I patients 100 86 77∗

Triage nurses must document triage assignments 100 93 100Triage nurses must report daily and monthly statistics of triage 100 93 100Triage nurses must consider hospital facilities when assigningpatients to triage level — Proposed 82

Diagnostic related interventions must be performed by triage nurses — Proposed 41∗

Therapeutic related interventions must be performed by triage nurses — Proposed 55∗

Physician must participate in prioritizing of patients in triage room — Proposed 77∗∗Less than consensus level of 80%.

results in shorter length of stay especially in overcrowdedconditions in the ED [24, 26]. Some studies suggested thatemergency nurse practitioners as an optimal choice havegreater impact on quality measures and financial indicesin ED [12, 27]. Comparison between the nurse practitionerand general practitioners demonstrated that the nurse prac-titioner can deal with patients effectively [12, 28] and they canbe assumed as superb candidates for expanded and extendedrole [29].

A limitation of the study is that the modified Delphimethod was used. Several modifications of the originalDelphi method have been described in the literature [30] andstandardized definitions of these modifications are not avail-able. Besides, panelists did not generally mention rationale incase of disagreement.

5. Conclusions

Triage nursing as a relatively new role for nurses is a challeng-ing role in a dynamic environment which needs significant

development to be practiced. Prioritizing is defined as thepivotal role for triage nurse. Comprehensive educational pro-grams and developmental research are required to supportdiagnostic and therapeutic interventions in triage practice bynurses.

Appendix

Search Strategies

Primary Search. Primary search included the following:(“triage” [MeSH Terms] OR “triage” [All Fields]) AND(“nurse’s role” [MeSHTerms] OR (“nurse’s” [All Fields] AND“role” [All Fields]) OR “nurse’s role” [All Fields] OR (“nurse”[All Fields] AND “role” [All Fields]) OR “nurse role” [AllFields]).

Competing Interests

The authors declare that there are no competing interests.

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Acknowledgments

Many thanks are due to Dr. Mojtaba Jafari for his help. Alsothe authors gratefully acknowledge all participants for theircooperation.

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